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Cartilage and arthrosis

Cartilage damage can occur acutely or chronically and is a common cause of persistent pain. It often begins with softening of the cartilage (chondromalacia). Marked symptoms occur in patients with cartilage damage, in the beginning, primarily on exertion such as descending mountains or stairs. These symptoms also occur over time during long periods of sitting. In the case of generalised cartilage damage or cartilage deterioration, we consider arthrosis. If there is no treatment, the cartilage becomes brittle, frays and breaks off. Once the cartilage is broken and the surface of the bone is exposed, severe symptoms usually occur on exertion.

Different treatment options are displayed using the knee joint:

>> Interview with Prof. Gäbler on the topic of arthrosis / vielgesundheit.at

Cartilage damage can occur on the patella or on the articular surfaces (femoral condyle, femoral head):


1) Patella

 

PATELLAR CHONDROPATHY

 

Softening of or damage to the cartilage on the back of the patella, accompanied by pain primarily when descending stairs or mountains and, over time, also on normal exertion.


TREATMENT

 

Investigation of the cause of the cartilage damage is crucial for treatment as malpositions can very often cause rapidly progressing cartilage damage.

Depending on the cause and the extent of the cartilage damage, either the cause will be treated (inserts, physical therapy, transposition operation, etc.) or the treatment will focus directly on the knee joint (cartilage structure treatment, microfractures, Pridie drilling, mosaicplasty, cartilage transplant, MPFL reconstruction), however arthroscopic assessment of the cartilage situation is often necessary.

Image: Pridie drill holes

The image shows pronounced cartilage damage on the back of the patella. By drilling holes through the patella (known as Pridie drill holes), you attempt to break through the sclerosed bone and achieve the growth of blood vessels. Replacement cartilage forms as a result of the migration of mesenchymal stem cells.

2) Articular surfaces on the femoral condyles

 

Cartilage damage here is predominantly found on the medial side of the joint. Different treatment measures are used depending on the extent of the damage:


MICROFRACTURES

 

For this, the bone is drilled through using a type of awl. The idea is the same as that of Pridie drill holes: you attempt to break through the sclerosed bone and achieve growth of the blood vessels. Replacement cartilage forms as a result of the migration of mesenchymal stem cells. The success rate in the case of microfractures is very good and is stated in literature as being up to 80%.

The advantage over Pridie drilling is that, in contrast to Pridie drill holes (in which very noticeable heat can be generated due to the rapid speed of the drill, which can lead to burning of the bone and vessels), the bone is opened using a type of awl in the case of microfractures. No heat damage occurs this way.

My results with microfractures are markedly good. After a few months, the cartilage damage is usually no longer discernible. In the event of small cartilage defects, I therefore prefer this method over cartilage transplantation (which is significantly more costly).
>> See also PDF / courier article from Aug. 2010

Image: Microfractures

With this intraoperative picture of arthroscopy, the holes that are left behind due to microfractures can be detected very easily.

Image: Mosaicplasty
MOSAICPLASTY

Smaller cartilage defects in the weight-bearing areas of the knee joint can be covered using this method. Cartilage is taken from sites in the knee joint where it is not required here (outside of the weight-bearing areas). However, small holes are formed with this method (donor defects), that can cause pain under certain circumstances. The removed cartilage cylinders are then inserted into the cartilage defect and left to heal there.

Mosaicplasty is a very good method for Ahlbäck's disease (= aseptic bone necrosis) and cartilage-bone defects, commonly also indicated in OCD (osteochondrosis dissecans) in the ankle.

Image: Cartilage transplant
CARTILAGE TRANSPLANT

Larger defects are covered using cartilage transplants, however cartilage must be removed in an initial operation for this. This cartilage is then cultivated and propagated outside of the body. Around six weeks after the initial operation, the newly cultivated cartilage can then be used as a transplant. The indication for cartilage transplant is very limited as there must not be any concomitant meniscus damage or opposing cartilage defect.


CARTILAGE SMOOTHING

 

I constantly see patients in my surgery who have undergone arthroscopy during which cartilage smoothing has also been carried out. At least in my practice, I can say that almost all patients feel worse after cartilage smoothing than before. I dare say that it depends on whether good cartilage is ground off as well, because it cannot be determined macroscopically during arthroscopy what is good cartilage and what is bad.

Scientific studies have clearly shown in the meantime that cartilage smoothing (mainly in elderly patients) not only leads to no improvement, but actually often even leads to a deterioration in the symptoms.

Unfortunately, cartilage smoothing is still stated in the guidelines for some Austrian and German associations – I personally see this method as incorrect treatment and can only advise each patient to not have it carried out.

Obvious exclusions are naturally those cases in which cartilage slough has to be removed, which would otherwise break away in the foreseeable future and lead to free floating loose bodies (also known as joint mouse).

Ineffectual cartilage smoothing - the fight for the knee (SWR)


ACP INFILTRATIONS

 

ACP (autologous conditioned plasma) is an autologous blood product for which the patient has blood removed from an arm vein and it is centrifuged in a special manner. Thrombocytes (blood platelets) are therefore activated, which, in turn release proliferative substances (such as Platelet Derived Growth Factor, PDGF) and morphogenic proteins (Transforming Growth Factor, TGF), which are important for muscle, tendon, cartilage and bone healing.

© Arthrex

New scientific studies show that the application of ACP can significantly accelerate and improve the healing of muscle injuries, as well as tendon and cartilage problems.

A clinical study of patients suffering from arthrosis recently showed that ACP infiltrations into the knee joint can lead to a marked improvement in the symptoms. The results of this study showed significantly better results for ACP in comparison to hyaluronic acid infiltrations.

Patient film about ACP therapy

>> Watch video

Top American Athletes Come to Europe for PRP Therapy
>> Read report

References:
Comparison Between Hyaluronic Acid and Platelet-Rich Plasma, Intra-articular Infiltration in the Treatment of Gonarthrosis

F. Cerza et al.; Am J Sports Med. 2012 Dec;40(12):2822-7.

Methods: A total of 120 patients affected by clinically and radiographically documented gonarthrosis were included in this study. The gonarthrosis was graded using the Kellgren-Lawrence radiographic classification scale. The 120 patients were randomised into 2 study groups in a 1:1 ratio: 60 patients received 4 intra-articular injections of PRP (specifically, autologous conditioned plasma [ACP], 5.5 ml), and 60 patients received 4 intra-articular injections of HA (20 mg/2 ml). An unblinded physician performed infiltration once a week for 4 weeks into the knee affected by clinically relevant gonarthrosis (in both groups). All patients were evaluated with the Western Ontario and McMaster (WOMAC) score before the infiltration and at 4, 12, and 24 weeks after the first injection.

Results: Treatment with a local injection of ACP had a significant effect shortly after the final infiltration and a continuously improving sustained effect up to 24 weeks (WOMAC score, 65.1 and 36.5 in the HA and ACP groups, respectively; P \ .001), where the clinical outcomes were better compared with the results with HA. In the HA group, the worst results were obtained for grade III gonarthrosis, whereas the clinical results obtained in the ACP group did not show any statistically significant difference in terms of the grade of gonarthrosis. The mean WOMAC scores for grade III gonarthrosis were 74.85 in the HA group and 41.20 in the ACP group (P \ .001).

Conclusion: Treatment with ACP showed a significantly better clinical outcome than treatment with HA, with sustained lower WOMAC scores. Treatment with HA did not seem to be effective in the patients with grade III gonarthrosis.


TREATMENT WITH MEDICATION in the case of joint pain and cartilage damage:

 

Please note that I have listed dietary supplements and medication that could but may not necessarily help you here. Some of these substances are praised in running circles as a nostrum, without serious studies having actually proven their effect. You can try out many yourself – the substances are certainly not harmful according to the current level of knowledge.

I currently recommend a 6-month treatment course of Orthomol Arthro Plus as cartilage reconstruction treatment. This combination preparation contains everything that I have prescribed previously individually or as a combination (see the preparations listed below) + vitamins and trace elements from orthomolecular medicine.

This treatment with Orthomol Arthro has proven itself mainly in marathon runners, who often complain of cartilage pain as a result of high levels of exertion – but also in patients who I have to operate on with cartilage damage.

I, personally, think very little of restorative cartilage injections: the puncture is painful, joint infections can occur and the efficacy is controversial. I have also not been able to verify yet whether patients feel better after an injection, compared to medication that can be easily swallowed.


Additional medications

 


1) CONDROSULF (Chondroitin sulfate)

 

The cartilage as a protective articular surface between the bones contains many different substances. It consists of cells and a base substance that is produced by the cartilage cells. Chondroitin sulfate is one of the main components in the cartilage base substance. This material inhibits the activity of the cartilage degrading proteins (enzymes). Taking chondroitin sulfate should promote the new synthesis of the cartilage base substance and make the cartilage more resilient. Chondroitin sulfate is a natural product and is obtained from the animal kingdom, like hyaluronic acid, either from fish (Condrosulf® preparation) or from chickens (Structum® preparation)

Both medications are usually taken as a treatment over a period of three months, once or twice a year. In order for Chondroitin sulfate treatment to be useful, reactive cartilage must be present. For this reason, it is advisable to use these preparations mainly in the early stage of arthrosis, and often also in the case of growth-related knee pain in adolescents.


2) HYALURONIC ACID

 

There have been many studies regarding hyaluronic acid to date. Hyaluronan, the sodium salt for hyaluronic acid, is a molecule similar to sugar, also called polysaccharide. The molecular structure of hyaluronan is a long chain made up of many identical links and hyaluronan is an important component of joint fluid. It is made by cells in the joint mucosa, released into the joint space and is responsible there for lubrication of the cartilage cover. The length of the hyaluronan chain influences the lubrication properties (viscoelasticity) of the corresponding preparation.


Mechanism of action

 

No precise mechanism of action has been described for hyaluronic acid. It has been determined, however, that the concentration of hyaluronic acid is markedly lower in arthritic joints than in healthy joints. Injection of hyaluronic acid into the affected knee joint should now improve the joint lubrication. Hyaluronan also has an anti-inflammatory effect.


Adverse effects

 

The manufacture of hyaluronic acid is varied. On the one hand, the substance is obtained from coxcomb, whereby the injection solutions can contain foreign proteins. If foreign proteins enter the blood, there is generally a risk of triggering hypersensitivity reactions. There are, however, other opportunities to manufacture hyaluronic acid. An example of this is the fermentative production, i.e. manufacture with the help of enzymes. The extent to which the differently manufactured hyaluronic acids differ in terms of their effect cannot be assessed definitively at this time.

Locally, concomitant symptoms such as pain, sensation of heat, erythema and swelling can occur at the treated joint. Hypersensitivity reactions have been observed in rare cases.


Dietary supplements

 


1) COLLAGEN HYDROLYSATE

 

Functioning cartilage requires both a close network of collagen fibres for internal fixation and for nutrient transport as well as a dense base substance, which is mainly made up of glucosamines. Athletes and professions involving severe joint strain have a high collagen requirement, as do rehabilitation and growth. Dietary supplementation with collagen should give the body the precise amino acids required for collagen construction. Using radioactively-tagged collagen hydrolysate has provided proof in animal testing that collagen fragments have actually been incorporated into the cartilage.

Additional studies showed that patients with slight arthrosis who were treated with collagen hydrolysate reported improved mobility of their joints and a reduction in pain, after around four to six weeks. The effect, however, has not been confirmed scientifically with prospective double-blind studies.

Dietary supplements with collagen hydrolysate are available in chemists and pharmacists as drinking ampoules as well as in powder form.


2) GLUCOSAMINE SULFATE

 

Glucosamine is an important building block of proteoglycans (glycosaminoglycans), the proteins that bind water to cartilage tissue, so that this retains a cushioning effect. As an important building block of joint lubrication, it should be responsible for its viscosity. The glycosaminoglycans therefore maintain the smoothness of the joints, support the provision of nutrients to the tissue in the joints and, as result, have an important function in the preservation and regeneration of the cartilage tissue. In addition, glycosaminoglycans support the composition and structure of the connective tissue.

Glucosamine is taken in the form of glucosamine sulfate. There are already numerous combination preparations on the market that contain both chondroitin sulfate and glucosamine sulfate, so that you only need to take one tablet. If you do not like taking tablets, you can also take glucosamine in the form of green-lipped mussel extract (young dogs are very often given green-lipped mussel extract to restore cartilage, it is also highly regarded in running circles).


3) GREEN-LIPPED MUSSEL EXTRACT

 

Mechanism of action of green-lipped mussel extract: Alongside vitamins, minerals and trace elements, the flesh of the green-lipped mussel contains many amino acids and a high percentage of materials similar to sugar, glycosaminoglycans (see above for effect). In addition to maintaining and building up the joint lubrication and the connective tissue, there is another aspect in the treatment of rheumatic diseases: the anti-inflammatory effect of the green-lipped mussel extract. This is attributed to the omega 3 fatty acids contained in the mussel. They inhibit the synthesis of prostaglandins from arachidonic acids and are therefore able to act against inflammatory processes.

Many runners swear by green-lipped mussel extract for non-specific joint pain and diffuse cartilage damage. The effect, however, has not been confirmed scientifically with prospective double-blind studies.


4) COMMON HORSETAIL CONCENTRATE

 

This contains a lot of silicone. The silicone from the common horsetail concentrate should support both the autologous collagen formation and the autologous formation of the base substance (support in glucosamine formation). The combination of common horsetail concentrate and collagen hydrolysate should be particularly effective.

The effect, however, has also not yet been confirmed scientifically with prospective double-blind studies.

 

Please note that medical indications and treatments change constantly. Sometimes these changes occur more rapidly than I am able to update on my homepage. Some information regarding dosage, prescription and compositions of medications may have changed in the meantime. Reading an internet page cannot replace visiting a doctor - it may be that during an examination and subsequent discussion with your doctor, other information is also communicated as a result of new scientific knowledge.

Interview with Prof. Gäbler on the topic of arthrosis

<b>>> Interview with Prof. Gäbler on the topic of arthrosis</b> <iframe width="393" height="278" src="http://www.vielgesundheit.at/index.php?id=365&movie_id=140"frameborder="0"></iframe>>> Interview with Prof. Gäbler on the topic of arthrosis