Chondral lesions accompanying
to acute and persistent tears
of anterior cruciate ligament of the knee joint,
based on video data made during 144 operations
Uszkodzenia chrz�stki stawów kolanowych stwierdzane
w czasie artroskopii stawów kolanowych u chorych z ostrymi
i zastarzaĆymi uszkodzeniami wićzadĆa krzy�owego przedniego
 na podstawie zapisów video 144 operacji
Grzegorz Adamczyk, Łukasz Antolak, Tomasz Skrok, Robert �migielski
Carolina Medical Center, Warszawa
Summary: Streszczenie:
An anterior cruciate ligament (ACL) injury leads to Uszkodzenie wićzadĆa krzy�owego przedniego sta-
instability, irreversible destruction of the articular wu kolanowego (WKP) prowadzi do niestabilnoĄci
cartilage and early degenerative changes of the knee stawu, uszkodzenia chrz�stek stawowych i wczes-
joint. The ACL damage is often accompanied by the nych zmian zwyrodnieniowych. Uszkodzeniu WKP
injury of the different anatomic elements of the jo- towarzysz� urazy pozostaĆych elementów anato-
int. At planning treatment, it is important to assess micznych stawu kolanowego. Przy planowaniu le-
the injuries of all components of the knee, as the se- czenia nale�y koniecznie uwzglćdnia� inne urazy
rious cartilage injuries accompanying ACL tear, re- i zmiany zwyrodnieniowe stawu wspóĆistniej�ce
quiring operation, at times make one-stage ACL re- z przerwaniem WKP, gdy� powa�ne uszkodzenia
construction impossible. chrz�stki, zĆamania chrzćstno-stawowe, urazy Ććko-
In our study we ve analysed video data obtained du- tek wymagaj�ce szycia, mog� uniemo�liwi� jedno-
ring arthroscopies of two groups of ACL deficient etapow� rekonstrukcjć WKP.
patients operated in Carolina Medical Center  72 Analizie poddano zapisy video 144 operacji pacjen-
patients with a recent tear (to 6 weeks post-injury), tów z uszkodzeniem WKP  72 ostrych, do 6 tygo-
and 72 with a chronic tear (more than 2 years dni od urazu i zastarzaĆych  powy�ej 2 lata po ura-
post-injury). Analysing our data we essayed to de- zie kolana. Analizuj�c uszkodzenia chrz�stki stawu
scribe evolution of joint cartilage with time from ac- kolanowego oceniane wg skali Outerbridge a próbo-
cident to surgery. [Acta Clinica 2001 2:138-144] waliĄmy Ąledzi� ewolucjć niestabilnego stawu kolano-
wego w czasie. Wyniki wskazuj� na postćpuj�c� de-
Key words: knee arthroscopy, ACL tear, chondro- gradacjć kolana, gĆównie w zakresie stawu rzepko-
malacia, early arthritis of the knee. wo-udowego, a nastćpnie piszczelowo-udowego.
W grupie pacjentów z chronicznym urazem WKP 2,5
razy czćĄciej obserwowano uszkodzenia chrz�stki IV�
wg Outerbridge a na bocznej powierzchni rzepki, na
powierzchni rzepkowej i na kĆykciach koĄci piszczelo-
wej. Znaczny procent pacjentów z chondromalacj�
chrz�stki w I grupie dowodzi choroby chrz�stki przed
urazem. Łćkotki mog� do pewnego stopnia ulega�
wygojeniu, czego dowodzi mniejszy procent pacjen-
tów uszkodzeniem Ććkotki bocznej w grupie I.
[Acta Clinica 2001 2:138-144]
SĆowa kluczowe: artroskopia stawu kolanowego,
przerwanie wićzadĆa krzy�owego przedniego, chon-
dromalacja, wczesna artroza stawu kolanowego.
138 " Czerwiec 2001
Chondral lesions of the knee joint
Introduction is richly innervated, constituting an impor-
tant tract of deep sensibility, and that is
Being the largest joint of the human or- why its damage leads to significant distur-
ganism, the knee joint consists of two sepa- bances of proprioception. Thus, arthrosco-
rate parts: the femoro-tibial joint and the pic reconstruction, after post-injury inflam-
femoral-patellar joint, covered with the mation calms, seems to be the optimum
common articular capsule. Because of rela- mode of treatment of this injury.
tively flat surfaces of bones constituting the It can happen sometimes that other in-
knee joint, the basic stabilising elements juries, accompanying the ACL lesion, i.e.
are: a system of internal and external liga- the meniscus injury requiring suture, serio-
ments, capsule, menisci and muscles. The us subchondral fractures, deep degenerative
elements increasing the frequency of inju- changes of the knee joint or malalignement
ries are: excessive height, overweight, repet- of the limb axis make the one-step recon-
itive microtrauma in sport or at work. struction impossible. That is why before
The growing social problem is consti- undertaking the decision; the surgeon sho-
tuted by premature wear of the articular uld have possibly complete information on
cartilage. Here again factors predisposing the injuries co-existing with the ACL, in
for the degenerative disease of the knee jo- order to decide on the appropriate opera-
int are: overweight, considerable height, tion and post-operative treatment. Ultraso-
malalignement of the limb axis and inju- nographic tests and the magnetic resonance
ries. It is assessed that in the adult popula- seem to be a very useful tool of pre-operati-
tion over 50 years of age, 80% have featu- ve assessment, but there are also still tech-
res of the knee joint degenerative changes nical limitations causing the need of verify-
(9, 11). ing the results. Diagnostic arthroscopy se-
One of the elements of the knee that ems to be the most efficient way of verifica-
undergoes injuries most frequently is the tion. There are still some controversies abo-
anterior cruciate ligament (ACL). It is esti- ut the importance of accompanying lesions
mated that in the United States happens on outcome, some authors state, that they
approximately 70,000 ACL ruptures in US have no influence on final result (4).
per year and 20.000 combined ACL/MCL Surgeons are often surprised by an ex-
lesions (11). Thus it can be estimated that tent of cartilage destruction and early dege-
every year in Warsaw, there take place ap- neration, which we observe during initial
prox. 1200 injuries of ACL. In 80% of pa- arthroscopy, few days after accident. Very
tients with massive knee haematoma, also interesting question might be rise up 
the ACL becomes damaged (totally or par- whether a certain level of joint degenera-
tially) (2, 4, 6, 12). Acc. to our studies, 4.4% tion isn t a  normal, healthy knee and to
of injuries in children are also knee haema- which extent anterior cruciate ligament re-
tomas. construction defends us against premature
The ACL injury is always a complex le- arthritis.
sion, accompanied by injuries of other ele-
ments: collateral ligaments, the meniscus, Aim of the study
osteochondral fractures, as well as there la-
ter develops inflammation of the synovial Quantitative description of chondral le-
membrane and cicatrisation within the sion accompanying ACL tear, in a group of
knee joint. The ACL is not only a mechan- patients with a recent, maximum 6 week
ical element, stabilising the knee joint, but old injury compared with intra-operative
Tom 1, Numer 2 " 139
Acta Clinica
observations of a group of patients with Tab. 2. Lesions accompanying
persistent, more than 2 years lesion. to anterior cruciate ligament tear
Material and method
II  persistent
Group I  acute tear
tear
Structure No  72
We marked chondral lesion accompan- No  72
Medial meniscus 83% 86,1%
ying ACL tear on adapted graphic scheme
Lateral meniscus 72% 51,3%
(6) (Fig. 1). 144 videotapes from anterior
Synovitis 94% 88,9%
cruciate ligament deficient patient, operated
Plica mediopatellaris 54,2% 61,1%
in CMC were analysed.
Lateralisation
23,6% 34,7%
of the patella
Statistical groups
Posterior cruciate
6,9% 11,1%
ligament lesion
Group I: 72 patients with a recent tear
Loose bodies 13,8% 22,2%
(within 6 weeks post injury).
Osteophytes 12,5% 37,5%
Group II: 72 patients with a persistent
tear (more than 2 years post injury).
Patients clinically evidently unstable,
with a Lachman (++), anterior drawer
Tab. 3. Operative procedures performed
(++) and pivot (+) test positive, but who
together with initial arthroscopy
arthroscopically present an anterior cruciate
ligament partial tear were also included in
our study (Fig. 2). I  Acute II  persis-
Group
lesion tent lesion
In chronic cases there s always a prob- Procedure
No  72 No  72
lem with date of an injury, quite often is
ACL reconstruction 37 31
difficult to precise, which-one of repetitive
Medial Collateral
Ligament reconstruc- 21
traumas is the final one. So, we decided,
tion
that the injury with a haematome, or con-
High tibial osteotomy 2 2
firmed by utrasounds or magnetic resonan-
Osteochondral grafts 3 7
ce, or the one that patient became sympto-
Microfracture 2 6
matic  it was an anterior cruciate ligament
Lateral meniscus suture 4 2
lesion (Fig. 3).
Medial meniscus suture 5 0
Arthrocare ACL plasty 3 3
Tab. 1. General information
Degree of cartilage destruction was
II  persistent
I  acute tear
Group tear
measured according to well-known Outer-
No  72
No  72
bridge (13) scale in following sites: 1. Pa-
34 years
Mean age 36 years (17  65)
tella  medial aspect, 2. Patella  lateral as-
(11  57)
pect, 3. Femur  intercondylar sulcus, 4.
Partial lesions 20,5% 21%
Period from inju- Femur  medial condyle, 5. Femur  late-
33 days 6,9 years
ry
ral condyle 6. Tibia  medial condyle, 7.
Sex F/M 34 / 38 31 / 41
Tibia  lateral condyle.
140 " Czerwiec 2001
Chondral lesions of the knee joint
Results: Tab. 8. Cartilage destruction
on lateral condyle of femur
Tab. 4. Cartilage destruction
on medial aspect of patella
Tab. 9. Cartilage destruction
on medial condyle of tibia
Tab. 5. Cartilage destruction
on lateral aspect of patella
Comments
Tab. 6. Cartilage destruction
on femoral intercondylar sulcus
Group of patients were comparable in
aspect of sex, age, percentage of partial,
symptomatic lesions. Group II is somehow
surprising, because many of these patients
were observed before arthroscopy, or trea-
ted by casts, rehabilitation or periarticular
ligamentoplasties or augmentations like
MCL suture.
Meniscal lesion may to certain extent
heal. It is well known, that instability leads
to meniscal destruction, but our observations
Tab. 7. Cartilage destruction
lead to conclusion, that during initial ar-
on medial condyle of femur
throscopy we probable too often decide, that
meniscus was wounded, what may be re-
sponsible for low percentage of LM lesion in
II gr and lack of evident MM destruction in
II group. Other features of osteoarthritis like
osteophytes, loose bodies and maltracking of
patella are evident in II group.
Lateralisation of the patella and high
ratio of III� and IV� lesion on lateral facet
Tom 1, Numer 2 " 141
Acta Clinica
Conclusions
ACL tear leads to knee degradation ob-
served as a progression of destruction in
a patella-femoral joint, and later femoro-ti-
bial joint.
Among patients with persistent tear 2,5
times more often IV� lesions were observed
in lateral aspect of patella, intercondylar
sulcus and tibia condyles.
Great percentage of chondromalacia
among patients with acute tear might mean
the chondral disease before an accident.
Meniscus tear might to certain level
heal spontaneously (lower percentage of
ML tear in II group).
In 50% of cases we reconstructed ACL
and other lesions as a one step procedure.
Fig. 1. Schematic drawings of cartilage lesions.
Discussion
of are results of maltracking of patella due
to secondary muscular imbalance and func- Osteoarthritis of the knee joint is a gro-
tional incompetence of medial head of wing both medical and social problem. Acc.
quadriceps muscle. to the American data, in the so-called  up-
From Tab. 4  9 is than visible, that lat- per middle class , there is one ACL injury
eral facet of patella and intercondylar sul- per 3 000 of adults a year, what results in
cus are the most often localisation of IV de- the necessity to perform approximately
gree lesions. 100 000 ACL reconstructions in the United
Cartilage repairing procedures like States every year (2, 4, 7). Active people,
OATS or microfractures were 3 x more of- working professionals, young, of high expec-
ten performed in a II group. Slightly lower tations towards their own organism, consti-
percentage of one-step ACL reconstruction tute the basic group of patients. Thus, such
in chronic group were due to the need of modes of treatment should be looked for
performing chondral procedures as a first which could be implemented without taking
step operation. them away from work or school.
Degenerative changes of menisci redu- Not all patients with the anterior cruci-
ced the possibility of meniscal sutures in ate ligament undergo surgical treatment.
persistent group. Two lateral meniscus su- The advanced age, advanced degenerative
tures were due to secondary lesions due to changes in the knee joint, osteoporosis of
accident of unstable knee joint. a considerable degree or inability to have
Medial condyle of femur is the most good contact with the patient constitute
common locus for IV degree lesion requir- predominating contraindication to recon-
ing OATS due to chronic antero-medial struction of the anterior cruciate ligament
rotatory instability with a LCL preserved (3, 4, 7, 11). Approximately 30% of pa-
and medial aspect of the knee chronically tients, in particular persons of small physi-
pivoting during walk. cal requirements, do not develop clinical
142 " Czerwiec 2001
Chondral lesions of the knee joint
Fig. 2  Partial lesions of ACL
Fig. 3 Magnetic resonance of ACL lesion, PCL laxity and MM lesion  bucket handle type
Fig. 4. Intraoperative photograph of ACL lesion, MM  bucket handle , chondral fractures
features of knee joint instability (11). Three ament injury up to 6 weeks after the acci-
years after an ACL tear, the cartilage inju- dent, already has degenerative changes of
ries become so deep (Outerbridge degree degree 3 and 4, which probably developed
3 and 4), that they are practically irreversib- before the injury (1).
le (4, 11). From our studies, however, it re- Thus, a very difficult question arises:
sults that almost 50% of patients we arthro- What does a  healthy normal knee of an
scopied because of the anterior cruciate lig- adult mean? Isn t a certain degree of dege-
Tom 1, Numer 2 " 143
Acta Clinica
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In our material, no  isolated injuries of
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1346  1355 01 876 Warszawa. Phone /Fax. [phone];
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144 " Czerwiec 2001