POST-TRAUMATIC
EROSIONS
H. V.
CROCK,
From
Erosions
internal
(Helfet
articular
of articular
cartilage
1956.
directed
Tallqvist
1962,
towards
the
erosions
after
injury,
1908; Wiles,
Andrews
with
and
joints
MELBOURNE,
St
Vincent’s
are
often
Hospital,
seen
The present
(Table
I).
paper
These
Meachim
clinical
1963).
diagnosis
Melbourne
in the
knee
the exception
Devas
1956).
papers
patients
with
to osteoarthritis
TABLE
JoINTS
AFFECTED
Joint
evolution
symptoms
cartilage
In
treatment
articular
in the
CARTILAGE
Number
.
I
Knee
.
.
.
11
.
.
I
.
.
3
on
is described
which
is neglected
Clinical
features-A
the
real
clinically.
specific
stresses
or direct
compression
For
example,
one patient
purpose
history
forces
injured
at
of the
of
injury
the
cartilage
affected
of this process
may be measured
in years.
Meanwhile,
and signs,
varying
with the pathology
in individual
cases,
erosions
(Figs.
I, 2, 5 and 6).
this series
diagnosis
was confirmed
not
appear
to have
articular
cartilage
patella
(BUdinger
injuries
in various
joints,
although
the
of patients
.
.
certain
EROSIONS
.
Wrist
does
of isolated
bearing
Hip
Elbow.
with
I
BY ARTICULAR
involved
in association
attention
management
of several
deals
with sixteen
lesions
predispose
joint
recurrent
subluxation
of the patella
have appeared
on the pathology
of
1957) and in experimental
animals
However,
and
CARTILAGE
AUSTRALIA
derangements
such
as meniscus
tears
or after
1959, Smillie
1962).
Also a number
of studies
cartilage
after
injury,
both
in man
(Landells
(Barnett
been
OF ARTICULAR
operation
paper
in every
is to draw
was
obtained
more
from
of short
duration
seemed
the articular
cartilage
of
a number
of disabling
can be attributed
to the
patient.
Although
attention
to a condition
each
to be the
the carpal
patient.
the
Shearing
cause of the lesions.
scaphoid
bone
by
wrenching
her wrist
when
she grasped
a bannister
to save herself
while falling
downstairs.
Another
developed
symptoms
in his right knee afterjarring
his leg while digging
in heavy clay.
A third developed
pain and recurrent
swelling
in the left knee after striking
the lateral
aspect
of the femoral
condyle
against
the sharp
edge of a desk.
The value of knowing
the direction
and nature
of the force producing
fractures
has been
described
by Perkins
(1956).
In the
provided
that the clinician
appreciates
This aspect
of an injury
to a joint
especially
The
main
crepitus
was not
with stiffness
severe,
but
aggravated
530
when
the
the injury
symptoms
pain,
has
were
present
context
this knowledge
is also of great importance
that the force may have damaged
the articular
cartilage.
is rarely
considered
in the surgical
teaching
of students,
not caused
bony damage.
found
to be pain, joint
swelling,
or instability
of weight-bearing
had a dull,
persistent
aching
as did
movement
or lifting
joints
character.
in the
upper
THE
and
transient
and
intermittent
(Table
II).
Usually
In the lower
limb
the pain
standing
limb.
JOURNAL
OF
BONE
AND
JOINT
SURGERY
POST
2. 1
Case
erosion
Figure
on the
near
2-The
medial
TRAUMATIC
EROSIONS
OF
ARTICULAR
CARTILAGE
..e medial
femoral
condyle
ofthe
right kneejoint
at operation
showing
the articular
cartilage
outer
border
of the condyle.
The
cruciate
ligaments
and
medial
meniscus
were
normal.
multiple
nodular
cartilaginous
loose
bodies
which
had come
from
the articular
cartilage
lesion
femoral
condyle,
shown
through
a lateral
incision.
Synovial
crepitus
had been
a constant
sign
on clinical
examination
of this joint
over many
months.
the
HG.4
,.j
Figure
3-Case
2. A lateral
radiograph
of the right
knee joint
showed
the localised
subarticular
at the femoral
condyle.
Figure
4-Case
3. An antero-posterior
radiograph
of the right
knee joint.
an extensive
area of damage
to the articular
cartilage
of the lateral
tibial
plateau,
and the localised
osteoporosis
VOL.
46 B,
L(8)
531
NO.
3,
AUGUST
1964
was confined
to this part.
osteoporosis
There
was
subarticular
532
H.
V.
CROCK
C,,
-
<0
L)
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
POST
VOL.
46 B,
NO.
3,
AUGUST
TRAUMATIC
1964
EROSIONS
OF ARTICULAR
CARTILAGE
533
534
H. V. CROCK
The
physical
signs
varied
with
the
joints.
Moderate
The effusion
effusions
were
tended
to recur
before
surgery.
after
erosions.
valuable
crepitus.”
be
elicited
have
acute
found
with
be
operation
occurring
in two
it
quite
in
the
called
an
affected
joint
flexed
crepitus,”
synovial
“
tenosynovitis.
This
FIG.
was
and
localisation
subsided
forms.
crepitus
area
knee
to
extent
always
distinct
resembled
the familiarjoint
only when
the damaged
been
condyles
will
but
sign.
nature,
of the articular
cartilage
seen more commonly
in affected
knees than in any other
or even to persist
during
the many months
of observation
while
in
that
physical
no
recur.
will
was
can
which
was
“
on
The
over
often
5
example.
rotated
position.
was
It could
For
be felt
FIG.
a
articular
ofchondromalacia.
being
other
Crepitus
be called
examined.
tibia
which
sign
not
which
or
was
the
degrees-but
resembled
a unique
did
first,
ofosteoarthritis
of cartilage
joint
95
and
The
it may
the
femoral
second,
a tendon
which
sheath
transient.
It was
in
due
6
Figure
5-Case
5. The left elbow, opened
from the lateral aspect, to show the articular cartilage
erosion
on the
capitulum.
Articular
crepitus
was produced
before
operation
by rotating
the head
of the radius
on the humerus
with
the elbow
flexed
to 90 degrees.
Figure
6-Case
12. The right
knee joint,
opened
from
the medial
side.
showing
the marginal
articular
cartilage
lesion.
Note
the ridging
of the articular
surface
of the medial
femoral
condyle
and the ingrowth
of pannus.
Synovial
crepitus
had been a prominent
physical
sign.
either
to
the
membranes
cartilage
especially
or
movement
to the
covered
at the
with
elbow
of fine
uneven
cartilaginous
movements
of
loose
bodies
caught
synovial
membrane
between
across
gliding
a ridged
synovial
area
of
pannus
(Fig.
6).
Some
restriction
of joint
movement
was common.
and wrist.
However,
under
anaesthesia
the range
of movement
was
normal.
Radiography
3 and
4).
circulation
suggested
This
revealed
sign
in adult
here
that
provoke
a twofold
reactionary
effusion.
was
areas
regarded
of localised
as a useful
subarticular
aid
bones
is complex.
particularly
the resorption
of metabolites
osteoporosis
in diagnosis.
The
in a few
anatomy
ofthe
patients
on the venous
side (Crock
1962).
from
the damaged
area
of cartilage
response:
firstly,
that this is probably
and secondly.
that resorption
ofthese
one factor
products
THE
JOURNAL
in the
through
OF
BONE
(Figs.
subchondral
It is
may
production
of the
the subchondral
ANt)
JOINT
SURGERY
POST
capillary
bed
may
TRAUMATIC
provoke
EROSIONS
a response
in the
peculiar
localisation
of the osteoporosis.
It is not possible
to offer
any suggestion
in patients
with
articular
cartilage
erosion
presented
in the
belief
that
they
may
OF ARTICULAR
subarticular
on
after
535
CARTILAGE
venous
leads
to this
the frequency
of this radiographic
injury.
However,
these
observations
finding
are
be of significance
in helping
plexus,
which
to establish
this
diagnosis.
Findings
at operation-Joint
fluid was usually
excessive
and contained
slimy
remnants
of
minute
articular
cartilage
flakes or multiple
small nodular
loose bodies
(Fig. 2). The synovial
membrane
and other intra-articular
structures
such as ligaments
or menisci,
appeared
normal.
When
the articular
cartilage
lesions
were situated
at some
distance
from
the joint
margins
their
appearances
discrete
varied
from
nodular
flakes
of cartilage
with
Wiles et al. (1956) described
as follows
from the
which
:
The
glistening,
applies
cartilage
synovial
nodular
blue
“
admirably
swellings
to fissured
rounded
free edges (Figs.
the naked-eye
appearances
area
normal
to some
is lustreless
cartilage
of the
and grey
surrounding
lesions
these
(Fig.
or erosions
surrounded
of the
or yellow
in colour,
and
it.”
This is an excellent
in this
injuries
was the ingrowth
of a highly
membrane,
which
sometimes
produced
cracks
1 and 5).
of chondromalacia
series.
vascular,
localised
A feature
patella
it is distinct
description
of marginal
flat, thin pannus
from
ridging
of the synovial
by
articular
the adjacent
tissues.
In
cases
the physical
sign of
synovial
crepitus
had been
found
before
exploration
6).
At operation
the lesions
were dealt with either by shaving
of the affected
areas of cartilage
until
smooth
surfaces
presented
or by combining
the shaving
procedure
with
closely
approximated
drill holes
penetrating
the subchondral
bone
plates.
The diameters
of the
“
drills
used
varied
between
one
“
millimetre
for carpal
bones
and
four
millimetres
for the femoral
condyles.
When
articular
of the subchondral
after
operation.
cartilage
erosion
bone plate had
However,
early
surgical
treatment
The results
of the cartilage
of treatment
are
occurred
been done,
movement
lesion.
set out
in weight-bearing
weight
bearing
was encouraged
in Table
areas,
and
was not allowed
irrespective
in which
drilling
for three months
of the method
of
III.
DISCUSSION
Isolated
lesions
of articular
cartilage
may
be found
after
injury
which
produced
neither
damage
to the bone nor to the other
components
of a joint.
For many
years the role of injuries
in the production
of chondromalacia
has
been
articular
recognised.
However,
cartilage
degeneration
the condition-to
et a!. 1956).
Some
and
unknown
injury
otherwise
of the
patella
primary
cause
simply
aggravating
of
produce
the characteristic
local changes
such as fissuring
or flaking
(Wiles
ofthe
patients
in this series fit into the category
ofthe
description
by Wiles
in others
the only demonstrable
lesions
in the affected
joints
and the adjacent
articular
cartilage
was normal.
There
is, therefore,
a clear distinction
to be drawn
between,
on the one hand,
joints
in
which
a wide area of articular
cartilage
is softened
and frankly
abnormal
to examination
at
were
his
even in this condition,
some
has usually
been implicated-the
has
colleagues.
localised
However,
cartilage
the time of operation-and
and, on the other
hand,
the exception
of a local
erosions,
in which there also exists some local change
of fissuring
those
in which
all the joint
cartilage
appears
and feels
erosion.
In the first instance
an injury
has aggravated
or flakingnormal,
with
a primary
degenerative
condition,
whereas
in the second
it has produced
a local erosion
in otherwise
normal
cartilage.
The diagnosis
of primary
post-traumatic
articular
cartilage
erosion
is difficult
to establish.
If the existence
of the lesion
were to be more
generally
appreciated,
then the diagnosis
would
be established
more often.
It is important
that this should
be so, because
it can cause protracted
VOL.
46 B,
L-l(8)
NO.
3,
AUGUST
1964
536
H.
V.
CROCK
TABLE
FINDINGS,
Case
Radiographic
number
Findis
findings
Normal
effusion
anterior
Localised
segment
of the
cartilage.
ised
over
lower
Multiple
end ofthe
femoral condyle
loose
area
of
erosion
condyle
Removal
Shaving
tibial
tilage
Menisci
bodies.
of
on
loose
bodies.
of the articular
the
No
car-
lateral
tomless.
cartilage
arthrotomy
Diagnosis
Removal
the
of
established.
bone
of loose
No
bodies.
loss
:
plate
osteo-
porosis
right
over the
lateral
erosion over the tibial plateau,
and on the posteriorhalfofthe
Extensive
articular
tibial
plateau
lateral
femoral
cartilage
condyles
and femur
drill
millimetre
tibia
of
shaved,
seen
effusion.
holes
made
tibio-femoral
in lateral
crepitus
c 0 m partment.
Movements
normal.
condyle
4).
Last
Large
Normal
erosion
femoral
of
the
condyle.
synovial
medial
Shaving
Scarred
dyles
the medial conof the tibia and femur
of
6
osteoporosis
lateral view
left capitulum
Normal
in
of
Localised
articular
erosion of capitulum
Cracked
surface
cartilage
of the lunate
Pre-patellar
Localised
7
Normal
erosion
cartilage
(Fig. 5)
Shaving
on
radial
bone
Shaving
cartilage
bursitis.
articular
on
the
Effusion
into
whitish flakes
ous material.
longitudinal
8
Normal
later
No residual
symptoms.
Full
movement of knee.
Last
seen
fourteen
months
later
ofproximal
of lunate
Symptoms
area
relieved.
Last
nine months
seen
later
of
the pre-patellar
Shaving
of
affected
seen
Symptomless.
movements.
articular
Excision
partly
later
Full
Last
four
months
Symptoms
changed
after
first operation
unthe
Improved
the
cartilage
lateral
edge
the joint
of soft
Two
splits
of eroded
bursa
of
the lateral
femoral
condyle.
Severe injection of the synovial
membrane
locally,
but
no
pannus formation
ular
seven
seen
tissues
Subarticular
5
No
crepitus.
months
4
sixteen
later
No
and one-
ex-
Slight
of full flexion.
months
Affected
No
Full
synovial
articular
(Fig.
effusion.
Last
No
3
seen
tension.
sub-
Localised
Symp-
later
crepitus.
Shaving
ofarticular
cartilage
and drilling
of subchondral
3)
Full
Last
four months
knee.
on the medial
femoral
(Figs. I and 2)
effusion.
movements.
tibial
condyle
Local-
articular
Result
flakes
Lateral
osteo-
porosis
(Fig.
with
sub-
articular
RESULTS
Treatment
ofcartilage
floating
in thejoint
from an erosion on the upper
articular
normal
2
AND
at operation
Moderate
I
III
TREATMENT
in
of
cartilage
after
second
Last
months
operation.
seen
four
later
with
gelatinparallel
the artic-
cartilage
in
the
intercondylar
area
of the
femur,
with
soft
flaky
articular
cartilage between them. A similar
lesion of the medial
facet of the patella
zone
Cartilage
femur
condyle
of the patella
and
shaved
and the femoral
drilled
Improved.
seen
two
later
Last
months
AND
SURGERY
articular
THE
JOURNAL
OF
BONE
JOINT
POST
TRAUMATIC
EROSIONS
OF
TABLE
FINDINGS,
Case
number
Radiographic
findings
9
Findings
Normal
Fissuring
cartilage
injection
of extensor
thumb,
10
Normal
AND
but
Erosion
of medial
Normal
RESULTS
of
Treatment
of lunate
Lunate
synovial
tendons
of
Slitting
no convincing
ab-
of
Result
shaved
extensor
at base
tendon
of thumb
of patella
Improved.
seen twenty
later
Last
months
Symptoms
not
seen
Improved.six
I
Greatlyfelt
and
bone
months
plate
of medial
months
Last
later
Shavingofarticularcartilage
and drilling
of subarticular
condyle
re-
lieved
Shaving
of erosion
of articular cartilage
of scaphoid,
and drilling
of subchondral
bone plate
of articular
cartilage
femoral
condyle,
and
chondromalacia
cartilage
sheath
normality
Oval area, six millimetres
wide,
of softened
articular
cartilage
on radial facet of the scaphoid
I
I
I
Ill-continued
TREATMENT
flaking
537
CARTILAGE
at operation
and
Slight
sheath
ARTICULAR
asimproved
though
a new leg.
she had
femoral
Last
seen
three
later
-
I
Erosion
of
I2
Normal
of
articular
medial
femoral
Cartilage
with
softened
pannus.
cartilage
Similar
of
I3
Normal
and
rim
tilage
of the head
lesion
towards
ing
6)
of
and
drilling
cartilage
femoral
on
of ar-
of
condyle,
of patellar
medial
and
Improving.
shav-
seen
car-
later
articular
Last
three
months
tilage
the
of the articular
pannus
wards
ticular
flaking
outer
with
I
Shaving
condyle.
(Fig.
patella
Softening
cartilage
and covered
car-
Cartilage
shaved.
tag removed
from
of the radius,
extending
the
radial
uphead
articular
car-
the
head
of
the
Synovial
between
radius
and
the capitulum
I
Greatly
Aching
improved.
relieved.
Last
seen
months
later
two
plateau
Ridging
tilage
:
S u b a r t i c ul a r
14
osteoporosis
right
medial
femoral
I5
of the
the patella
of
plane
on
the
in a vertical
medial
side
severe post-traumatic
I
of the middle
ella.
ular
condyle
Normal
Heaping
cartilage
condylar
area
Severe
softening
ellar cartilage.
medial
femoral
and
softening
area
of the pat-
the articthe interthe femur
up of
in
of
of
Fissuring
condylar
the
pat-
Shaving
I
drilling
I
of the
car-
tilage
Normal
for
16
Posterior
which
showed
localised
subarticular
bone
erosion
location
cartilage
appeared
in
weight-bearing
area of acetabulum
46 B,
and
Shaving
articular
andcartilage
drilling
medial
shaving
femoral
condyle,
of the patellar
ticular
cartilage
of the
the
of
Greatly
improved.
Last
months
seen
later
Improved.
two
Last
and
ar-
seen
Mental
condition
area
restored
to normal.
later
one
month
except
tomograms
plate
VOL.
of the cartilage
of the subchondral
of the femur
bone plate
NO.
3,
AUGUST
I
arthrotomy
and
disof the hip.
Articular
of the femoral
head
normal.
Localised
erosion
ofthearticularcartilage
in the
weight-bearing
the acetabular
1964
roof
area
of
I
Shaving
of the affected
of cartilage.
subchondral
weight
bearing
months
after
Drilling
of the
bone plate.
No
until
operation
four
Hip
improved.
Continued
to limp
intermittently.
Last
months
seen
later
eleven
538
H.
disability
years
after
before
joint
the
injury.
Some
underlying
cause
of the
was
V.
CROCK
patients
in the
recognised
and
present
treated.
series
In the
had
been
meantime
disabled
they
had
for
been
labelled
as psychoneurotics.
The clinical
picture
of recurrent
effusions,
persisting
aching
pain
in the joint
together
with the signs of crepitus
of two distinct
varieties,
after a specific
injury
should
bring
this diagnosis
to mind.
Radiography
may provide
useful confirmatory
evidence
ifthe
sign oflocalised
subarticular
osteoporosis
can be demonstrated.
Tomography
is also sometimes
useful.
The anatomical
basis of the radiographic
findings
in this condition
has been discussed.
In regard
to treatment,
no authoritative
statement
can be made at the present
time.
From
the results
presented
in this series
cartilage
may be useful
in preventing
general
The
agreement
rationale
on the potentialities
of articular
of drilling
the subchondral
bone
of osteoarthritis
appears
it is clear
that
shaving
the shedding
of loose
of the
reasonable
knee,
(Pridie
but
its application
of the affected
area
bodies
into the joint.
cartilage
for
plate has been
to the
of articular
There
is no
repair
after shaving.
discussed
in the management
treatment
of articular
cartilage
erosion
1959).
SUMMARY
I.
Sixteen
as have
2.
patients
with
The
to
articular
crepitus
diagnosis.
3. A radiographic
sign
“
4.
articular
cartilage
the results
of their treatment.
clinical
features
of this rarely
The
surgical
combination
“
and
of localised
treatment
of shaving
used
with
diagnosed
synovial
“
drilling
erosions
are
as useful
“
subarticular
shaving
subchondral
injury
have
discussed.
physical
osteoporosis
either
of the
slight
condition
crepitus
was
after
affected
bone
described,
Attention
signs
is reported
of the
been
and
area
is drawn
in establishing
the
discussed.
of
cartilage
or
a
plate.
I wish to thank my wife, Dr M. C. Crock,
and Miss M. Philipps
for their help in preparing
this paper.
The
photographs
were produced
with great care by Mr A. Daniel
and Mr E. Moir, whose assistance
I appreciate.
I thank also Dr Gordon
Donnan
and Dr P. H. Cody who offered useful comments
on the radiographic
findings.
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