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Special concerns come into play when treating athletes with cartilage injuries
Palliative and reparative surgical options and nonoperative treatments are the primary treatments.
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Treating athletes with cartilage injuries presents specific challenges and calls for special decision making as many patients desire to return to pre-injury activity levels or better.
Brian J. Cole, MD, MBA, described the considerations and treatment options for these patients at the 8th World Congress of the International Cartilage Repair Society.
“Keep in mind that chondrosis may be incidental,” Cole said. “We are treating the here-and-now. We do not know what the true natural history is with or without treatment. Nonoperative treatment is still the mainstay for the performing athlete. Make no promises to those who cannot perform. Short-term solutions may be acceptable for the competitive athlete and long-term solutions are probably most appropriate for the recreational athlete.”
Pre-, post-, and in-season events, contract issues, medical red-shirt availability and the length of the patient’s career factor into the decision-making process.
Nonoperative options are reserved for athletes with a new onset of symptoms, symptomatic patients who can maintain their performance, those with compromised performance in a contract year or those in their last year of play.
Surgery is an option for patients who have impaired performance, a red-shirt remaining, pain with low-level activity, failed conservative treatment or based upon certain contractual issues and guarantees as well as patient preferences.
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Nonoperative treatment
In Cole’s practice, NSAIDs are a mainstay for symptomatic patients. He also uses glucosamine and chondroitin sulfate. However, he acknowledges that the literature is limited regarding the efficacy of the supplements.
Patients may also benefit from topical agents and injectable corticosteroids. Although there are no studies examining the effect of corticosteroids in athletes, research has shown longer-term improvement with higher doses.
“These effects tend to wane after 6 to 8 weeks, but given the minimal morbidity that may be okay for certain athletes,” Cole said. In addition, he uses hyaluronic acid in athletes with known osteoarthritis (OA).
Emerging research using blood-derived growth factors also shows promise.
“There is some pre-clinical work and early clinical work that suggests that autologous conditioned plasma exposed to glass beads elicits synthesis of anti-inflammatory cytokines, including interleukin-1 receptor antagonist,” Cole said.
Rehabilitation is a mainstay in his treatment and it has been shown to increase the rate of knee loading and reduce adduction moments.
Surgery
With respect to surgical options, the concept of “marginal gain” is invoked such that the symptom resolution expectations must be realistic by all involved parties and the end result should be one of reduced symptoms and improved activity levels. Cole said that physicians can tell patients that microfracture, in general, allows 44% to 77% of patients to return to competition and recent reports suggest that more than 50% return to their preinjury level of play, especially in professional basketball players. However, the literature suggests that there is a functional decline after 24 months.
The return to athletic activity after osteochondral autograft is 61% to 93%. Younger patients, those with smaller defects and those who are treated early have better outcomes with the procedure, he said.
Although osteochondral allografting can lead to high patient satisfaction, there is little data investigating the procedure in athletes.
Autologous chondrocyte implantation can lead to significantly improved activity scores in 72% to 96% of patients, a return to high-impact activity in 33%-96% and return to competition in 83%, Cole said.
For more information:
- Brian J. Cole, MD, MBA, section head of the Rush Cartilage Restoration Center, Rush University Medical Center, 1725 W. Harrison St., #1063. Chicago, IL 60612, 312-432-2300, bcole@rushortho.com. He has indicated he receives grant research funding from and is a consultant to Genzyme.
Reference:
- Cole BJ. Injury repair options in the athlete — special concerns. Paper #1.4. Presented at the 8th World Congress of the International Cartilage Repair Society. May 23-26, 2009. Miami.