Stav Gare

10/30/15
Annotated Bibliography
ENC1102
One of the Most Important Joints in the Body, the Knee
Since the beginning of history, people use their knees on a daily basis.
However, in more recent years because of the fact that the lifespan of the
average human has grown, there has been more prominent damage to the
knee specifically in the articular cartilage. Articular cartilage is the layer of
cartilage covering the end of a bone that forms a joint surface, providing,
among its many functions, shock absorption, even distribution of load across
the joint and nutrition of the underlying bone(Livingstone). Because
articular cartilage damage is very prevalent, especially in Florida because of
the large amount of elderly people, there are various facets that need to be
taken into consideration to prevent degeneration of cartilage. In each article
in this annotated bibliography there are many different aspects of articular
cartilage that are being discussed, but some information is beyond the scope
of this research conversation. For example, the measurements of each injury
werent included in this annotated bibliography nor were illustrations of
criterion that was included or excluded because it isnt relevant for this
conversation. This research conversation focuses on what can effect and lead

to injury in the articular cartilage in the knee, the people it effects, the
effects of anterior cruciate ligament reconstruction (ACL) and running on the
cartilage in the knee, surgeries for articular cartilage knee damage, the
measuring tools used to assess the damage, how these techniques differ,
and the outcome of these techniques. Although many studies are new and
are inconclusive for long term affects, these are all cited in this paper
because they portray the complexity and difficulty a surgeons decision
entails in order to ensure their patient receives the correct care.
The sources in this conversation are primarily from academic journals
because this is an academic profession. The authors of these academic
journals include doctors of medicine, PhDs, researchers, and students in
medical schools. This academic profession, the medical field, grows
exponentially every year and new information is constantly discovered. Even
though the history in medicine is important because it gives a base for new
discoveries, in order to stay up to date and discuss the most relevant
conversation the cited information stems from the last twenty years.
Although there are constant changes in this field, doctors from all over the
world are updated with the most current and best techniques making the
medical field a global conversation. Furthermore, because the medical field
incorporates many specific terms this conversation is meant for seniors in
college majoring in biomedical sciences.

Anderson, Allen F., and Christian N. Anderson. "Correlation Of Meniscal And

Articular Cartilage Injuries In Children And Adolescents With Timing Of
Anterior Cruciate Ligament Reconstruction." American Journal Of
Sports Medicine 43.2 (2015): 275-281. SPORTDiscus. Web. 10 Oct.
2015. In the American Journal of Sports Medicine in February 2015, Dr.
Allen F. Anderson and Dr. Christian N. Anderson explicate on the effects
of Anterior Cruciate Ligament Reconstruction on articular cartilage
injuries in children and adolescents. They first discuss the anterior
cruciate ligament (ACL) injuries and treatments in pediatric patients.
Past techniques included noninvasive procedures that were thought to
have more pros than cons, but recent studies show that if surgery isnt
done at a young age, there is a high probability of cartilage damage in
the future. This study was done through the reviewing of one hundred
thirty adolescent patient records from 2000-2012 who have had ACL
reconstruction surgery. This included surgeries that were done acutely
(up to six weeks), subacutely (six to twelve weeks), and chronicly
(more than three months) after injury. Through this research, the
higher likelihood of cartilage injury after ACL surgery is shown to be
associated with age, increasing time to surgery, sports activities before
reconstruction, and any instability episode. In order to prevent
cartilage damage from occurring, surgeries to previous injuries in the
knee need to be taken care of.

Biant, Leela C, et al. "Long-Term Results Of Autologous Chondrocyte

Implantation In The Knee For Chronic Chondral And Osteochondral
Defects." The American Journal Of Sports Medicine 42.9 (2014): 21782183. MEDLINE. Web. 22 Oct. 2015. Leela C Biant, George Bentley,
Sridhar Vijayan, John A. Skinner, and Richard W.J. Carrington are
researchers in the science and medical fields and work at the Royal
National Orthopedic Hospital in Stanmore, UK. This study analyzes the
long term effect of autologous chondrocyte implantation (ACI) of the
knee on one-hundred and four patients. ACI is an effective procedure
on damaged articular cartilage in the knee that has a potential to
produce hyaline cartilage. Ten years after the surgery was performed,
the patients were annually assessed and asked for feedback.
Approximately ninety eight percent of these patients said they were
satisfied and that if the soreness happened in their other knee they
would get ACI surgery. Although ACI is a fairly new procedure, this midterm technique has been deemed successful and promising as a
primary cartilage repair method.

Camp, Christopher L., Michael J. Stuart, and Aaron J. Krych. "Current

Concepts Of Articular Cartilage Restoration Techniques In The Knee."
Sports Health: A Multidisciplinary Approach 6.3 (2014): 265-273.
SPORTDiscus. Web. 11 Oct. 2015. Christopher L. Camp, Michael J.

Stuart, and Aaron J. Krych are all doctors of medicine at the

Department of Orthopedic Surgery and the Sports Medicine Center,
Mayo Clinic and Mayo Foundation in Rochester, Minnesota. Through a
clinical review of outcome studies published from 1993 to 2013,
restoration techniques for damaged articular cartilage have been
collected. By using magnetic resonance imaging to recognize cartilage
damage in the knee, there has been an increase in the amount of
patients with cartilage injury. If non-operative techniques dont subdue
pain and injury, then surgical techniques need to be taken place. A
technique that is included in this medical journal is microfracture.
Although short term results seem to be promising, Only 52% of
microfracture patients were able to return to sport at preinjury levels
after surgery (Camp,Stuart,Krych, 268) proving that microfracture is
less sufficient for athletes. Other techniques include osteochondral
autograft transfer (more reliable for athletes), osteochondral allograft
transplant (large chondral defects), and autologous chondrocyte
implantation. The journal then concludes with three phases of
rehabilitation, which includes healing, transition, and remodeling.
Through this clinical review different techniques and their statistics
were illustrated to provide evidence for the best treatments for
articular cartilage knee damage.
Chang, Ke-Vin, et al. "Comparative Effectiveness Of Platelet-Rich Plasma
Injections For Treating Knee Joint Cartilage Degenerative Pathology: A

Systematic Review And Meta-Analysis." Archives Of Physical Medicine

& Rehabilitation 95.3 (2014): 562-575. SPORTDiscus. Web. 12 Oct.
2015. Through electronic database from September 2013, using metaanalysis, and placebo controls, Doctors of medicine in Taiwan Ke-Vin
Chang, Chen-Yu Hung, Fanny Aliwarga, Tyng-Guey Wang, Der-Sheng
Han, Wen-Shiang Chen discuss treating damage in the cartilage of the
knee through injecting platelet-rich plasma. Unlike intra-articular
corticosteroid injections that results are limited to one month, plateletrich plasma(PRP) injections are a natural concentrate of autologous growth
factors from the blood, is an emerging regenerative therapy for tissue injury and
degeneration (Chang, et al 563). Out of sixteen studies where 1,543 patients were given
PRP injections, patients with knee cartilage degenerative pathology showed promising
results for at least twelve months. Although there is a time limit for the effectiveness of
PRP, through this analysis there is proven to be a significant functional improvement with
these patients. This study is relevant to my topic because it provides a new technique,
platelet rich plasma injections, being used for patients with cartilage damage in the knee.
Donaldson, James, Francois Tudor, Ian D. McDermott. "(Iv) Treatment Options for
Articular Cartilage Damage In The Knee." Orthopaedics & Trauma 29.1
(2015): 24-30 7p. CINAHL Plus with Full Text. Web. 10 Oct. 2015. James
Donaldson and Tudor Francois are fellows in orthopedic surgery in
Holland, and Ian D. McDermott is a consultant orthopedic surgeon in
London. They emphasize that choosing a specific orthopedic surgery
on an adolescent is a more difficult decision to make than orthopedic

surgery on an adult because complications in the future are more likely

to occur. Their article discusses the science behind articular cartilage
and treatments for articular cartilage damage. These treatments
include microfracture, which is a form of bone marrow stimulation
where debridement of all unstable articular cartilage around the
defect down to subchondral bone (Donaldson, Tudor, McDermott, 24).
By reporting on seventy-one follow up patients under the age of forty
-five for eleven years, it was proven that there were significant
improvements of cartilage damage in the knee. Other treatment
techniques included abrasion arthroplasty, autologous chondrocyte
implantation, radiofrequency chondroplasty, autologous matrixinduced chondrogensis, chondrotissue, autologous osteochondral
transplantation, and osteochondral allografts. Most of these techniques
are lacking in data over a large span of years, but the technique best
suited for adolescents based on reports is microfracture. This is
relevant to articular cartilage damage in the knee because it discusses
different treatments and their rankings based on results.
Emre, Tuluhan Yunus, et al. "Factors Affecting The Outcome Of Osteochondral
Autografting (Mosaicplasty) In Articular Cartilage Defects Of The Knee
Joint: Retrospective Analysis Of 152 Cases." Archives Of Orthopaedic
And Trauma Surgery 133.4 (n.d.): 531-536. Biological Abstracts 1969 Present. Web. 22 Oct. 2015. Tuluhan Yunus Emre, Tolga Ege, Ozkan
Kose, Demet Tekdos Demircioglu, Bahadir Seyhan, and Macit Uzun

work in hospitals and military medical clinics in two cities, Ankara and
Antalya, in Turkey. Although there are many different procedures done
to repair damaged articular cartilage in the knee, in this retrospective
study these authors focus on the factors affecting the outcome of
autologous osteochondral grafting, also known as mosaicplasty.
Mosaicplasty is a technique which involves obtaining small-sized cylindrical
osteochondral grafts from the minimal weight-bearing periphery of the femoral condyles
at the level of the patella-femoral joint and transplanting them to prepared defect sites on
the weight-bearing surfaces (Emre, et al, 532). By evaluating one hundred fifty two
previous patients who underwent mosaicplasty, they discovered that age, size of lesion,
and location of lesion are just a few factors that affect the long-term success of this
procedure. This procedure is just one of many that physicians must contemplate between
to choose the most successful surgery for their patient.

Gudas, Rimtautas, et al. "Ten-Year Follow-Up Of A Prospective, Randomized

Clinical Study Of Mosaic Osteochondral Autologous Transplantation
Versus Microfracture For The Treatment Of Osteochondral Defects In
The Knee Joint Of Athletes." American Journal Of Sports Medicine 40.11
(2012): 2499-2508. SPORTDiscus. Web. 22 Oct. 2015. Rimatautas
Gudas, Agne Gudaite, Anroldas Pocius, Asta Guediene, Emilis
Cekanauskas, Egle Monastyreckiene, Algidus Basevicius are doctors of
medicine and PhDs in Lithuania. In the past decade there has been
several procedures done to repair damaged cartilage in the knee, but

Osteochondral Autologous Transplantaion(OAT) has been the only one

step surgery that repairs fibrocartilage in the knee. These doctors used
a randomized control trial of sixty athletes that underwent either
microfracture procedure or OAT from the years 1998 until 2002 to
compare the results. Through ten years of follow ups, OAT and
microfracture both had successful outcomes, but OATs study had more
athletes return to preinjury activity. Although clinical trials on OAT are
inconclusive because its a more recent procedure, there are promising
results up to ten years. OAT is another technique that is used to repair
articular cartilage in the knee and seems to be one of the most
successful.

Hambly, Karen. "The Use Of The Tegner Activity Scale For Articular Cartilage
Repair Of The Knee: A Systematic Review." Knee Surgery, Sports
Traumatology, Arthroscopy 19.4 (2011): 604-614. SPORTDiscus. Web.
12 Oct. 2015. Karen Hambly is part of the faculty/researcher of Life
Sciences in the London Metropolitan University in London,UK. Through
the use of electronic database and reference lists from other articles
from the year 1984 until 2009, Hambly explains how the Tegner
Activity Scale is used after treatments for articular cartilage damage in
the knee and provides estimates of the procedures effectiveness. The
Tegner Activity Scale (TAS) is used when studying knee populations
because it measures the activity level of a person at different times

and is one of the easiest and speediest activity scales that are used
today. In thirty four studies where TAS was used postoperatively, eighty
eight percent showed improvement in TAS scores after articular
cartilage repair. The TAS is one of several scales used, but it is
important to explain because it has a significant part in scaling activity
of an individual after repairing articular cartilage damage.
Ji-Hoon, BAE, et al. "Articular Cartilage Of The Knee 3 Years After ACL
Reconstruction." Acta Orthopaedica 86.5 (2015): 605-610.
SPORTDiscus. Web. 19 Oct. 2015. Ji-Hoon Bae, Ali Hosseini, Yang Wang,
Martin Torriani, Thomas J Gill, Alan J Grodzinsky, and Guoan Li are in
several medical schools ranging from Harvard University to Korea
University College of Medicine. They used T2 relaxation times, an MRI
system, on ten patients to evaluate the cartilage of the knee three
years after ACL surgery. The use of T2 relaxation times detects
biochemical changes in the construction of cartilage in the knee, which
can lead to discovering an early onset of cartilage degeneration. Four
compartments of the articular cartilage of the knee were analyzed in
order to see the effects of ACL surgery: medial femoral condyle, lateral
femoral condyle, medial tibial plateau, and lateral tibial plateau. The
students of medicine then compared these sections of the knee to the
patients other knee that didnt have any injury. They discovered that
seven patients were able to return completely to their sport activities
and only occasionally had pain in their knee after training. ACL is just

one surgery that can affect atrophy of knee cartilage, but by discussing
the after effects of ACL surgery leads to acknowledging the fact that in
a close range time frame after the surgery it is overall successful.

Li, Hong, et al. "Quantitative MRI T2 Relaxation Time Evaluation Of Knee

Cartilage: Comparison Of Meniscus-Intact And -Injured Knees After
Anterior Cruciate Ligament Reconstruction." American Journal Of
Sports Medicine 43.4 (2015): 865-872. SPORTDiscus. Web. 12 Oct.
2015. Doctors of Medicine Hong Li, Shuang Chen,Hongyue Toa, and
Shiyi Chen of the department of sports medicine in Shanghai use
magnetic resonance imaging(MRI) to study the appearance of knee
cartilage after anterior cruciate ligament reconstruction(ACL). By
gathering data on sixty two male patients that underwent ACL
reconstruction, an advanced MRI technique using T2 relaxation time
values gives information on the effects on the cartilage. Their study
illustrated that after ACL reconstruction and meniscal repair, the change of T2
articular cartilage value was not reversible (Li et al, 871) and had greater deterioration in
articular cartilage. The MRI T2 relaxation time value is only one technique used to
evaluate the effects of ACL reconstruction on articular cartilage in the knee.
Maldonado, Diogo Correa, et al. "The Effects Of Joint Immobilization On
Articular Cartilage Of The Knee In Previously Exercised Rats." Journal Of
Anatomy 222.5 (2013): 518-525. Academic Search Premier. Web. 19

Oct. 2015. Diogo Correa Maldonado, Marcelo Cavenaghi Pereira da

Silva, Seman El-Razi Neto, Monica Rodriguez de Souza, and Romeu
Rodriguez de Souza study Genetics, anatomy, or physical education in
Brazil. At times joint immobilization is deemed necessary after certain
injuries, but it stimulates degeneration of the articular cartilage. By
testing twenty male Wistar rats subject to aerobic exercise five times a
week and putting them into four groups of a control group, immobilized
group, exercised group, and an exercised group then immobilized,
these students examined the effects of joint immobilization on articular
cartilage of the knee. It is known that exercise can slow down the
degeneration of cartilage in knees and this study has proven that. The
study of the rats that were in the exercised group proved that exercise
protects cartilage thickness among other things verifying that
exercised rats can prevent an early onset of atrophy of cartilage in the
knee. Although this study was tested on rats, it still provides key
information proving that exercise is one way to slow down the cartilage
degeneration in the knee.

Montgomery, Scott, et al. "Trends In The Surgical Treatment Of Articular

Cartilage Defects Of The Knee In The United States." Knee Surgery,
Sports Traumatology, Arthroscopy 22.9 (2014): 2070-2075.
SPORTDiscus. Web. 11 Oct. 2015. From the department of orthopedic

surgery in the David Geffen School of Medicine at UCLA in Los Angeles,

Scott Montgomery, Brock D. Foster, Stephanie S. Ngo, Rodney D.
Terrell, Jeffrey C. Wang, Frank A. Petrigliano, and David R. McAllister
discuss surgical treatments for articular cartilage damage in the knee.
They use current procedural technology and a national insurance
database to search and then analyze different surgeries for articular
cartilage repair. Some of these surgeries in the United States are
chondroplasty, microfracture, osteochondral autograft, osteochondral allograft, and
autologous chondrocyte implantation (ACI). Out of 163,448 surgeries from 2004 until
2009, the procedures that were mainly implemented were chondroplasty and
microfracture. These techniques were mainly performed to people who were middle aged
opposed to the other techniques that were primarily for younger patients. Although
damage of articular cartilage is common, there are various techniques that are best suited
for people based on the size of the damage, exact placement, sex, age etc.
Schindler, Oliver S. "(Iv) Articular Cartilage Surgery In The Knee."
Orthopaedics & Trauma 24.2 (2010): 107-120 14p. CINAHL Plus with
Full Text. Web. 12 Oct. 2015. In a biomedical journal in the UK, Oliver S.
Schindler discusses surgeries that are practiced. He is professionally
affiliated with a consultant orthopedic surgeon, Droitwich Knee Clinic
and Birmingham arthritis and Sport Injury Clinic in Droitwich Spa,
Worcestershire, UK. In Schindlers research he states that ten thousand
people in the UK suffer from cartilage damage in the knee. Because of
the exponential growth of cartilage injuries in the past two decades,

orthopedic surgeons have become creative with technology to find

solutions for these knee problems. In this article, Schindler discusses
and expounds upon different techniques used to repair cartilage injury
of the knee. The repair techniques are marrow stimulation,
replacement techniques, and cell based repair techniques. Schindler
also criticizes each repair technique stating which ones are better than
the others. These techniques are vital to repair articular cartilage in the
knee, but they are only a part of the after effect of damage. This is
important to state because injury is increasing and one needs to know
in a case where injury occurs what measures to take.
Schttler, Karl, et al. "Use Of Cell-Free Collagen Type I Matrix Implants For
The Treatment Of Small Cartilage Defects In The Knee: Clinical And
Magnetic Resonance Imaging Evaluation." Knee Surgery, Sports
Traumatology, Arthroscopy 22.6 (2014): 1270-1276. SPORTDiscus.
Web. 12 Oct. 2015. Karl Shuttler, Hanno Schenker, Christina Theisen,
Markus Schofer, Alan Getgood, Phillip Roessler, Johannes Stuewer,
Marga Rominger, and Turgay Efe are medical doctors in different
hospitals and clinics in Germany and Canada. These physicians
evaluate the use of cell-free collagen type I matrix implants to treat
damage to articular cartilage in the knee. Cell-free collagen type 1
matrix implants are one step procedures that use former matrices in a
stand-alone, cell-free manner to serve as a carrier for chondrocytes to colonize the defect
in vivo (Schuttler, et al, 1271). This type of implant leads to high quality repair tissue

similar to the value of healthy tissue. This procedure was implemented among fifteen
patients in the University Hospital in Marburg, Germany. These patients then had follow
ups for the next 48 months. In the beginning there was no significant improvement, but
after three years there was. Because this study is quite recent and there arent many cases
with this procedure the results are only related to mid-term successes. Besides the
standard surgeries, this study shows one alternative technique for the articular cartilage
damage in the knee for midterm improvements.
Subburaj, Karupppasamy, et al. "The Acute Effect Of Running On Knee
Articular Cartilage And Meniscus Magnetic Resonance Relaxation Times
In Young Healthy Adults." American Journal Of Sports Medicine 40.9
(2012): 2134-2141. SPORTDiscus. Web. 12 Oct. 2015. Karuppasamy
Subburaj, Deepak Kumar, Richard B. Souza, Hamza Alizai, Xiaojuan Li,
Thomas M. Link, and Sharmila Majumdar attend University of San
Francisco and study Radiology and imaging research. They introduce
the effect of running on articular cartilage in the knee by emphasizing
that tissue cartilage in the knee joint is responsible for the absorption
of shock and stability. By using the MRI to see how running affects the
structure of the knee, the study results were significant in high activity
performance exercises. These students took twenty healthy volunteers
and took an MRI before activity and then instructed them to run for
thirty minutes. When taking a second MRI after their run there was a
change in the composition of cartilage. In the knee joint there was
fluid shifts in the extracellular collagen matrix (Subburaj, et al,

2138), proving that after running, even in healthy active people, there
is an acute effect of running on articular cartilage in the knee.
Ravnihar, Klemen, Ariana Barli, and Matej Drobni. "Effect Of Intra-Articular
Local Anesthesia On Articular Cartilage In The Knee." Arthroscopy: The
Journal Of Arthroscopic & Related Surgery: Official Publication Of The
Arthroscopy Association Of North America And The International
Arthroscopy Association 30.5 (2014): 607-612. MEDLINE. Web. 19 Oct.
2015. Doctor of medicine Klemen Ravnihar, doctor of philosophy Ariana
Barlic, and doctor of philosophy and doctor of medicine Matej Drobnic
work in hospitals and medical centers in Ljubljana, Slovenia. There has
been research proclaiming that even short-term exposure to local
anesthetics leads to chondrocyte death and dysfunction(Ravnihar,
Barlic, Drobnic, 607) These doctors used national autologous
chondrocyte implantation registry and hospital records to analyze the
use of general anesthesia, spinal anesthesia, or local anesthesia on
forty- nine patients from 2009 until 2013 on articular cartilage in the
knee. Although they hypothesized that anesthesia has a toxic effect on
articular cartilage in the knee, their study failed to prove this. Although
anesthesia primarily does not have any negative effects on articular
cartilage, it is not conclusive and is important to state because it is one
study that examines a possible procedures effect on cartilage in the
knee.

Rodriguez-Merchan, EC. "Regeneration Of Articular Cartilage Of The Knee."

Rheumatology International 33.4 (n.d.): 837-845. Science Citation
Index. Web. 22 Oct. 2015. E Carlos Rodriquez-Merchan is a doctor in La
Paz University hospital in Madrid, Spain. He gathered clinical studies
from PubMed since 2006-2012 to summarize certain aspects of
articular cartilage, specifically different techniques and its criteria used
for regenerating articular cartilage damage in the knee. The
procedures discussed were gene activated matrices, autologous
chondrocyte implantation (ACI), matrix induced ACI, microfracture,
osteochondral autograft transfer, biological approaches, osteotomies,
stem-cell-coated titanium implants in osteochondral defects, and
chondroprotection with pulsed electromagnetic fields. Every method
has its pros and cons, but it is important that the a surgery is
performed in order to prevent an early onset of degeneration of
articular cartilage.

Widmyer, Margaret R., et al. "High Body Mass Index Is Associated With
Increased Diurnal Strains In The Articular Cartilage Of The Knee."
Arthritis & Rheumatism 65.10 (2013): 2615-2622 8p. CINAHL Plus with
Full Text. Web. 19 Oct. 2015. Margaret R. Widmyer, Gangadhar M.
Utturkar, Holly A. Leddy, Jeremy L. Coleman, Charles E. Spritzer, Claude
T. Moorman III, Louis E. DeFrate, and Farshid Guilak attend and work at
Duke University and Duke University Medical Center. They

hypothesized that people with higher than average body mass index
(BMI) are more likely to have strains in articular cartilage, which can
lead to osteoarthritis. They tested twenty patients changes in
thickness of cartilage in the knee, half with a normal range BMI and the
other half with higher range BMI. Although there may be other factors
that affect deterioration of cartilage in the knee, in this study they
focus on the effect of overweight bearing and straining on knee
cartilage. In conclusion, a higher BMI is correlated to damaging
cartilage in the knee that can lead to osteoarthritis. This study is
important to include primarily because it shows how weight has a large
effect on joints and cartilage.

Work Cited:
"articular cartilage." Dictionary of Sport and Exercise Science and Medicine
by Churchill Livingstone. 2008. Elsevier Limited 25 Oct. 2015 http://medicaldictionary.thefreedictionary.com/articular+cartilage